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770-475-2377

Patient Portal

Home
About Us
Our Doctors
- Providers at Alpharetta
- Providers at Cumming
Services
Specialty Procedures
Patient Resources
Insurance
Blog
Contact

Release of Medical Information

Our goal is to help you enjoy your life in optimal health as long as possible by combining the scientific strengths of modern medicine with an emphasis on personal, patient-doctor relationship.

Services

Physical Examination
Men’s Health
Women’s Health
In-House Lab Testing
Cologuard®
Cancer Screenings

Echocardiography
Holter Heart Monitor
Stress Test
Carotid Ultrasound Imaging
Cholesterol Maintenance
Joint Pain – Rheumatology

Proud Members

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Bone Density Questionnaire

Name *

Date *

Is there a chance that you are pregnant? *

YES
NO

Have you a barium x-ray in the last 2 weeks? *

YES
NO

Have you a barium x-ray in the last 2 weeks? Have you had a nuclear medicine scan or injection of an x-ray dye in the last week? *

YES
NO

Have you had hyperparathyroidism or a high calcium level in your blood? *

YES
NO

IF YOU HAVE ANSWERED YES TO ANY OF THE ABOVE, SPEAK TO THE RECEPTIONIST IMMEDIATELY

2. Your Ethnicity: *

Caucasian
Black
Asian
Hispanic
Other

Your Ethnicity Other *

3. Have you ever had a bone density test? *

YES
NO

If YES, when and where? *

4. Have you had a recent weight change? *

YES
NO

If YES, tell us about it *

5. Your tallest height (late teens or young adult) *

6. Have you ever broken a bone? *

YES
NO

Simple Fall? *

What was your age when the fall occurred *

If not a simple fall, please describe circumstances below: *

7. Has a parent or sibling had a broken hip from a simple fall or bump? *

YES
NO

8. Has a parent or sibling had any other type of broken bone from a simple fall or bump? *

YES
NO

9. How many times have you fallen in the last year? *

10. Have you ever had surgery of the spine, hips, legs or arms? *

YES
NO

If YES, describe what type of surgery and which side was affected. *

11. Are you currently receiving, or have you previously received prednisone pills (cortisone)? *

YES, Currently
YES, previously
NO

If YES, how long? *

What dose? (MG) *

Pills each day *

12. Do you smoke? *

YES
NO

13. Alcohol: 3 or more units per day *

YES
NO

14. List any chronic medical conditions that you have: *

15. Are you currently receiving, or have you previously received any of the following medications?

Medication for seizures of epilepsy *

YES
NO

How long? *

Chemotherapy for cancer *

YES
NO

How long? *

Medication for prostate cancer *

YES
NO

How long? *

Medication to prevent organ transplant rejection *

YES
NO

How long? *

16. Have you been treated with any of the following medications?

Alendronate (Fosamax) *

Ever?
Currently?

If current, how long? *

Boniva *

Ever?
Currently?

If current, how long? *

Calcitonin (Miacalcin Nasal Spray) *

Ever?
Currently?

If current, how long? *

Hormone Replacement Therapy (Estrogen) *

Ever?
Currently?

If current, how long? *

Intravenous Pamidronate (Aredia) *

Ever?
Currently?

If current, how long? *

Prolia *

Ever?
Currently?

If current, how long? *

PTH (Forteo) *

Ever?
Currently?

If current, how long? *

Raloxifene (Evista) *

Ever?
Currently?

If current, how long? *

Reclast *

Ever?
Currently?

If current, how long?

Risedronate (Actonel) *

Ever?
Currently?

If current, how long? *

Tamoxifen *

Ever?
Currently?

If current, how long? *

Testosterone *

Ever?
Currently?

If current, how long? *

Zoledronic Acid (Zometa) *

Ever?
Currently?

If current, how long? *

17. How many servings of the following do you eat/drink per day (on average)?

Milk (Full cup) of servings *

Orange Juice fortified w/ calcium (Full cup) of servings *

Yogurt (Small container or½ cup) of servings *

Cheese of servings *

18. Do you take any calcium supplements (including TUMS) *

YES
NO

19. Do you take any Vitamin D supplements (including multivitamins & halibut liver oil) *

YES
NO

FOR WOMEN ONLY

20. Are you still having menstrual periods? *

YES
NO

21. Before menopause, have you ever missed your-periods for 6 months or more *

YES
NO

Besides During pregnancy

22. Have you had your menopause? If YES, what age? *

YES
NO

What age? *

23. Have you had a hysterectomy? If YES, what age? *

YES
NO

What age? *

24. Have you had both ovaries removed? If YES, what age? *

YES
NO

What age? *

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